Provider Demographics
NPI:1891018321
Name:ANDERSON, KATHRYN S (RPH)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:S
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 BAILEY FARM RD
Mailing Address - Street 2:TARGET PHARMACY T-2024
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950
Mailing Address - Country:US
Mailing Address - Phone:845-783-5682
Mailing Address - Fax:845-783-5682
Practice Address - Street 1:128 BAILEY FARM RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-4952
Practice Address - Country:US
Practice Address - Phone:845-783-5682
Practice Address - Fax:845-783-5682
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037562183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02709644Medicaid